Pak

1
Dr. A. Siswanto
OCCUPATIONAL HEALTH
WITH MONEY YOU

GO SEE A DOCTOR
BUT NOT HEALTH
Tenaga kerja dalam melaksanakan

pekerjaannya memiliki risiko terpapar
berbagai faktor bahaya di tempat kerja,
baik sebagai akibat dari pekerjaannya
maupun kondisi lingkungan kerja, yang
dapat mengakibatkan berbagai gangguan
kesehatan atau timbulnya penyakit akibat
kerja.
Salah satu upaya yang perlu dilakukan untuk
meningkatkan kesehatan tenaga kerja adalah
penyelenggaraan pelayanan kesehatan kerja.
5
WHAT IS OCCUPATIONAL HEALTH ?
The discipline of occupational health

is concerned with the two-way
relationship of work and health.
Occupational health involves
maintaining the state of well-being
and freedom from occupationally
related disease of injury.
6
OCCUPATIONAL HEALTH
The provision of occupational health service
to
the workforce requires managerial and union
involvement. A large number of
professionals
are also involved, including :
Physicians
Nurses
Occupational hygienists
Lawyers
7
OCCUPATIONAL HEALTH
Continued
Toxicologists
Health physicists
Microbiologists
Epidemiologists
Ergonomics
Safety engineers
8
OCCUPATIONAL MEDICINE
Occupational medicine (kedokteran
kerja) is the clinical speciality
concerned with the diagnosis,
management and prevention of
diseases due to or exacerbated by,
workplace factors.
9
The main attributes and functions of a

doctor
working in industry are :
a. Knowledge of the work environment
b. Clinical skill in the early detection of ill health
c. Knowledge of relevant legislations
d. Pre-placement, periodic and special medical
examinations
e. Administrative responsibility for nursing and
first-aiders
f. Treatment
g. Health education and health promotion
h. Rehabilitation
10
The main attributes and functions of a

doctor
working in industry are :
Continued
i.
Teaching and research

j. Advice to individuals , management,
organized
labor and safety representatives
k. Maintenance and review of clinical and
environmental records
l. Surveillance of groups at specific risk, e.g.,
lead
workers, compressed air workers, occasional
drivers
m. Liaison with outside organizations ---11
government,
Industrial Hygiene
AIHA (American Industrial Hygiene
Association) defines Industrial Hygiene as :
the science and art devoted to the anticipation,
recognition, evaluation, and control of those
environmental factors or stresses arising in or
from the workplace which may cause sickness,
impaired health and well-being, or significant
discomfort among workers or among the
citizens of the community .
12
OCCUPATIONAL HEALTH NURSING

Attention in the field of occupational health
nursing has shifted from a narrow focus on
communicable disease, maternal and child
health issues, and emergency treatment of
injured workers to a much broader focus today.
Presently, the occupational health nurse (OHN)
applies public health principles to meet the
needs of workers in an ever-changing work
environment.
13

The focus of the OHN have thus expanded to
include integration of many areas, including
epidemiology, industrial hygiene,
environmental health, toxicology, safety,
management, health education, early
disease detection, disease prevention, health
promotion, and health and environmental
surveillance.
14

The OHN, whether employed as a single health
care provider at a small plant or as a member
of a multidisciplinary health unit, must balance
ethical and clinical responsibilities to
employees with ethical and administrative
responsibilities to management.
This balance requires the OHN to assist
management in providing a safe and healthful
work environment through disease prevention
and health promotion activities.
15

Some of the responsibilities include :
The daily operation of a comprehensive
health care program;
Development of treatment and
surveillance protocols;
Keeping informed about health and
safety regulation;
Maintenance of a toxic substance list;
16

Identification of high risk areas;
clinical intervention, including delivery

of health care and counseling
services;
Record keeping;
Liaison with managers, workers, and
health and safety colleagues; and
Implementation of health-related
programs.
17
OCCUPATIONAL HEALTH NURSE
The role of the occupational health nurse has

changed rapidly over the past two decades.
Originally, the nurse was employed in the
organization to provide a treatment and
first-aid service, dealing with accidents and
illness at work.
The provision of nursing has developed to
encompass all aspects of preventive health
care.
18
It is important for everyone to understand

the role of the nurse in the workplace. It
should encompass all those factors which
affect the health of people at work.
The occupational health nurse must be
pro-active and flexible in order to
influence the health of employees and
those within the wider sphere of
community outside the organization.
19

The qualified occupational health nurse
may be an autonomous practitioner who
can perform many functions either
alone, or as part of a wider team of
physicians, hygienists, safety officers,
etc.
20

He or she will carry out functions such as health
supervision including :
Pre-employment health assessment;
Follow-up assessments following illness or injury;
Assessment of those with known health problems
and those working in potentially hazardous
environments;
Development and implementation of immunization
and vaccination programs;
Hazard identification and control;
Counseling;
Health promotion and supervision and training of
first-aid personnel.
21

The occupational health nurse is an advisor
to both management and employees; therefore

it is imperative that the advice given is correct,
is given in the right manner and is unbias.
In the United Kingdom, there are approximately
9000 nurses working in the field of occupational
health, the majority of which work without the
support of a full-time medical officer; many
have only a visiting GP with little or no
occupational health training or experience.
22

The American Association of Occupational Health
Nurses (AAOHN) defines occupational health nursing
as :
The application of nursing principles in conserving
(dalam melindungi) the health of workers in all
occupations.
It emphasizes prevention, recognition, and treatment
of illnesses and injuries and requires special skill and
knowledge in the fields of health education and
counseling, environmental health and human
relations.
23
DONAL HUNTER
(1898-1978)
No one can be expected to be

familiar with the details of all
occupations and every working
environment, but at least he should
take the opportunity to study those
industries which fall within the area
of his practice
24
De Morbis Artificum Diatriba

Bernardino Ramazzini (1633-1714) :
I hesitate and wonder whether I should bring
bile to the noses of doctors ---- they are so
particular about being so elegant and
immaculate ---- if I invite them to leave the
apothecarys shop which is usually redolent of
cinnamon and where they linger as in their
own domains, and to come to the latrines and
observe the diseases of those who clean out
the privies.
25
Kesehatan Kerja
Menurut komite bersama ILO dan WHO,
Kesehatan Kerja (Occupational Health) didefinisikan
sebagai suatu aspek atau unsur kesehatan yang
erat berhubungan dengan lingkungan kerja dan
pekerjaan, yang secara langsung maupun tidak
langsung dapat meningkatkan efisiensi dan
produktifitas tenaga kerja.
26
TUJUAN KESEHATAN KERJA

1. Meningkatkan dan memelihara derajat kesehatan
tenaga kerja yang setinggi-tingnya baik jasmani,
rohani maupun sosial untuk semua lapangan
pekerjaan.
2. Mencegah timbulnya gangguan kesehatan yang
disebabkan oleh kondisi kerja.
3. Melindungi tenaga kerja dari bahaya kesehatan
yang timbul akibat pekerjaan.
4. Menempatkan tenaga kerja pada suatu
lingkungan kerja sesuai dengan kondisi fisik, faal
tubuh dan mental psikologis tenaga kerja yang
bersangkutan.
27
PROGRAM KESEHATAN KERJA

1.
2.
3.
4.
Pemeriksaan kesehatan
Diagnosis dan pengobatan
Pemantaun/monitoring tempat kerja
Pengamanan bahaya bahan kimia di
tempat kerja
5. Pelatihan dan pendidikan
6. Pengadaan alat pelindung diri
7. Pencatatan dan pelaporan
8. Penilaian epidemiologis
9. Evaluasi secara berkala
10. Usaha lainnya.
28
PELAYANAN KESEHATAN KERJA
29
Permen Nakertrans No. 3 Tahun 1982

Dalam peraturan ini, yang dimaksud dengan
Pelayanan Kesehatan Kerja adalah suatu usaha
kesehatan yang dilaksanakan dengan tujuan :
1. Memberikan bantuan kepada tenaga kerja
dalam
penyesuaian diri baik fisik maupun mental,
terutama dalam penyesuaian pekerjaan dengan
tenaga kerja;
2. Melindungi tenaga kerja terhadap setia
gangguan kesehatan yang timbul dari
pekerjaan
atau lingkungan kerja;
30

3. Meningkatkan kesehatan badan,
kondisi
mental (rohani), dan kemampuan fisik
tenaga kerja;
4. Memberikan pengobatan dan
perawatan serta rehabilitasi bagi
tenaga kerja yang menderita sakit.
31
Tugas Pokok Pelayanan Kesehatan

Kerja
a.
b.
c.
d.
e.
Pemeriksaan kesehatan sebelum kerja,

pemeriksaan berkala dan pemeriksaan
kesehatan khusus;
Pembinaan dan pengawasan atas
penyesuaian pekerjaan terhadap tenaga kerja;
Pemembinaan dan pengawasan terhadap
lingkungan kerja;
Pembinaan dan pengawasan perlengkapan
sanitasi;
Pembinaan dan pengawasan perlengkapan
untuk kesehatan tenaga kerja;
32

Kerja
f. Pencegahan dan pengobatan terhadap
penyakit umum dan penyakit akibat kerj
g. Pertolongan pertama pada kecelakaan;
h. Pendidikan kesehatan untuk tenaga kerja
dan latihan untuk petugas pertolongan
pertama pada kecelakaan;
33

Kerja
i. Memberikan nasehat mengenai
perencaan dan pembuatan tempat
kerja, pemilihan alat pelindung diri
yang diperlukan dan gizi serta
penyelenggaraan makanan di tempat
kerja;
34

Kerja
j. Membantu usaha rehabilitasi akibat

kecelakaan
atau penyakit akibat kerja;
k. Pembinaan dan pengawasan terhadap tenaga
kerja yang mempunyai kelainan tertentu
dalam
kesehatannya;
l. Memberikan laporan berkala tentang
pelayanan
kesehatan kerja pada pengurus.
35
Penyelenggaraan
Pelayanan Kesehatan Kerja
Penyelenggaraan Pelayanan Kesehatan
Kerja
dapat :
1. Diselenggarakan sendiri oleh pengurus;
2. Diselenggarakan oleh pengurus dengan
mengadakan ikatan dengan dokter atau
Pelayanan Kesehatan lain;
3. Pengurus dari beberapa perusahaan secara
bersama-sama menyelenggarakan suatu
Pelayanan Kesehaan Kerja (Pasal 4 PerMen
Nakertrans No. 3 tahun 1982).
36
Penyelenggaraan
Penyelenggaraan Pelayanan
Kesehatan Kerja dipimpin dan
dijalankan oleh dokter yang disetujui
oleh Direktur(pasal 5 PerMen
Nakertrans No. 3 tahun 1982).
Pengurus wajib memberikan
kebebasan profesional kepada doker
yang menjalankan Pelayanan
Kesehatan Kerja.
37
Penyelenggaraan
Dokter dan tenaga kesehatan dalam
melaksanakan Pelayanan Kesehatan
Kerja, bebas memasuki tempattempat kerja untuk melakukan
pemeriksaan dan mendapatkan
keterangan yang diperlukan (pasal 6
KepMen No. 3 tahun 1982).
38
Penyelenggaraan
Pengurus wajib menyampaikan laporan pelaksanaan
Pelayanan Kesehatan Kerja kepada Direktur (pasal 7
KepMen Nakertrans No. 3 tahun 1993).
Dokter maupun tenaga kesehatan wajib

memberikan keterangan tentang pelaksanaan
Pelayanan Kesehatan Kerja kepada Pegawai
Pengawas Keselamatan dan Kesehatan Kerja jika
diperlukan (pasal 8 KepMen Nakertrans No. 3 tahun
1983).
39
Masalah Kesehatan Kerja Di

Perusahaan
Pelayanan kesehatan kerja di perusahaan
umumnya bersifat kuratif, sedangkan
pendekatan preventif biasanya kurang
mendapat perhatian.
Pengertian dan kesadaran pimpinan perusahaan

dan pekerja terhadap kesehatan kerja umumnya
masih jauh dari apa yang diharapkan, kecuali di
beberapa perusahaan saja dimana kesehatan
kerja betul-betul telah diterapkan.
40
Masalah Kesehatan Kerja Di

Perusahaan
Lingkungan kerja di perusahaan sering kurang/
tidak manusiawi dan bahkan tidak jarang
keadaannya berada pada tingkat yang
membahayakan baik terhadap kesehatan
maupun keselamatan tenaga kerja.
Keadaan gizi tenaga kerja umumnya masih
belum menguntungkan produktivitas kerja.
Perencanaa dan pemikiran tentang
penserasian manusia dan mesin atau
pekerjaan serta usaha perbaikan sikap dan
cara kerja yang sesuai dengan prinsip-prinsip
ergonomi umumnya belum/tidak diperhatikan.
41
Peranan dan
Fungsi Personil Kesehatan
Kerja
Di perusahaan-perusahaan dimana Pelayanan
Kesehatan Kerja ditangani oleh seorang
perawat perusahaan yang bekerja secara full
time dan seorang dokter yang bekerja secara
part time, maka dalam keadaan ini peranan
perawat tersebut dalam menerapkan
kesehatan kerja di perusahaan sangat
ditentukan oleh pengetahuan dan
keterampilannya dalam bidang keselamatan
dan kesehatan kerja.
42
Peranan dan
Kerja
Pada prinsipnya adalah tidak
beralasan bila perawat yang telah

terdidik dan terlatih di bidang
kesehatan kerja dan keselamatan
kerja tidak dibenarkan untuk
menyelenggarakan pelayanan secara
kompeten program keseahatan kerja
di perusahaan.
43
Peranan dan
Kerja
Dokter perusahaan harus benar-benar
dapat bertindak sebagai occupational

physician dan merupakan key individual
serta berperan aktif dalam proses penentuan
suatu keputusan yang berkaitan dengan
program kesehatan kerja di perusahaan.
Keterlibatan dokter perusahaan dalam
aktifitas manajemen terutama yang
berhubungan dengan kesehatan kerja akan
semakin dibutuhkan.
44
PENYAKIT AKIBAT KERJA
45
Where an occupational
disease is suspected, Donald
Hunters advice is to ask
whether any similar illness has
occurred in a fellow
workman.
46
Paracelsus sebagai seorang dokter di

Villach Austria dan seorang pakar
metalurgi (metallurgist) antara lain
mengatakan bahwa :
We must have gold and silver, also other
metals, iron, tin, copper, lead and mercury.
If we wish to have these, we must risk both
life and body in a struggle with many
enemies that oppose us.
47
Agricolas statement that in

the
mines of the Carpathian
mountains,
women are found who have
married
seven husbands, all of whom
this
terrible consumption has
carried off
to a premature death.
48
DE RE METALLICA
(AGRICOLA, 1556)
The disease that prevailed in the mining

community.
At that time mortality from pulmonary
diseases was not recorded, nor were the
causes known, but they would have included
deaths from silicosis and tuberculosis, and
from lung cancer due to the mining of a
radioactive or in siliceous rock.
49
PENYAKIT AKIBAT KERJA

Penyakit akibat kerja adalah istilah yang
dipakai dalam peraturan yang dibuat atas
dasar UU No. 1 tahun 1970 tentang
keselamatan kerja, sedangkan penyakit yang
timbul karena hubungan kerja merupakan
istilah yang erat kaitannya dengan
kompensasi (ganti rugi) kecelakan kerja.
50

Setiap penyakit akibat kerja yang
ditemukan dalam pemeriksaan kesehatan
berkala atau khusus harus dilakukan secara
tertulis kepada Kandep Tenaga Kerja
setempat selambat-lambatnya 2 x 24 jam
setelah penyakit tersebut dibuat
diagnosisnya.
Dalam peraturan ini dilampirkan penyakit
akibat kerja yang harus dilaporkan.
51
UU No. 3 tahun 1992 mengatur tentang

Jaminan Sosial Tenaga Kerja (Jamsostek)
Peristilahan dalam UU Kecelakaan tahun
1947 dilanjutkan penggunaannya dalam UU
No. 3 tahun 1992 tentang Jamsostek.
Menurut UU No. 3 tahun 1992, penyakit yang
timbul karena hubungan kerja termasuk
kecelakaan kerja atau kecelakaan yang
terjadi berhubungan dengan hubungan kerja.
52
Kepres No. 22 Tahun 1993

Didalam Kepres ini tercantum berbagai jenis
penyakit yang berkaitan dengan hubungan
kerja.
Setiap tenaga kerja yang menderita penyakit
yang timbul karena hubungan kerja berhak
mendapat jaminan kecelakaan kerja baik pada
saat masih dalam hubungan kerja maupun
setelah hubungan kerja berakhir.
53
Baik penyakit akibat kerja maupun penyakit

yang timbul karena hubungan kerja
mempunyai pengertian yang sama yaitu
penyakit yang disebabkan oleh pekerjaan
atau lingkungan kerja. Dengan kata lain
penyakit akibat kerja sama dengan penyakit
yang timbul karena hubungan kerja.
54
Menurut literatur dan bukan menurut

ketentuan perundang-undangan yang berlaku,
penyakit yang bertalian dengan pekerjaan
yang merupakan terjemahan dari workrelated disease diartikan sebagai
penyakit yang penyebabnya
multifaktor/jamak, sedangkan pekerjaan
atau lingkungan kerja adalah salah satu dari
penyebab tersebut.
55
Work-related diseases may be partially

caused by adverse working conditions.
They may be aggravated, accelerated, or
exacerbated by workplace exposures, and
they may impair working capacity.
Personal characteristics and other
environmental and sociocultural factors
usually play a role as risk factors in workrelated diseases, which are often more
common than occupational diseases.
56
Outline of The Occupational
Descriptions of all jobs held

Work exposures
Timing of symptoms
Epidemiology of symptoms or illness
among
other workers
Non work exposures and other factors
57
DESCRIPTIONS OF ALL JOBS HELD

Job titles alone are not sufficient :
An electrician may work in a plant where lead
storage batteries are manufactured;
It may be useful to have the patient describe a
typical work shift from start to finish and simulate
the performance of work task by demonstrating
the body movement associated with them.
A visit to the patients workplace by the
physician
may be necessary and is always informative.
58
Work Exposure
The patient should be carefully
questioned about working conditions

and past and present chemical,
physical, biologic, and psychologic
exposures.
Also inquire about unusual accidents or
incidents such as spills of hazardous
materials that may be related to
patients problems.
59
Work Exposure (Continued)

It should be determined if personal
protective equipment /PPE (such as
gloves, work clothes, masks, respirators,
and hearing protectors) has been
provided, and if yes, when, and how
often the workers have used this
equipment.
60
Work Exposure
If PPE is being used, determine if it
appears to fit and work properly.
Ask whether protective engineering
systems and advices such as ventilation
systems are present in the workplace
and whether they seem to function
adequately.
61
Timing of Symptoms
Information on the time course of the
patients symptoms is often vital in
determining a given diseases or syndrome is
work-related or not.
Since latent periods vary, occupational
etiologies should not be ruled out because
timing of symptoms does not initially
correlate with time at work.
62
Timing of Symptoms
The following questions are often useful :
Do the symptoms begin shortly after the start of
the workday?
Do they disappear shortly after leaving work?
Are they time-related to certain processes, work
task, or work exposure?
Have you recently begun a new job, worked with
a new process or been exposed to a new
chemical in the workplace?
63
Epidemiology of Symptoms or
Illness
Further what the affected workers share in

common such as similar job, exposure,
physical location in the workplace, age, or
sex. Birth defects among offspring, fertility
problems, cancer incident, and high
turnover workers or their early retirement
for health reasons.
64
Epidemiology of Symptoms or Illness
The patients knowledge of other workers

at the same workplace or in similar jobs as
well who are suffering from the same
symptoms or illness may be important clue
to recognizing work-related disease.
Unfortunately, workers may not always be
aware of symptoms present in coworkers.
65
Non Work Exposure and Other

Factors
A synergistic relationship between
occupational and non occupational
factors in causing disease;
The physician should ask if the patient
smokes cigarettes or drink alcohol;
Regarding recent exposure to new
soaps, cosmetics, and clothes.
66

Factors
The physician should also ask :
a. Does the patient have hobbies (such
as wood-working or gardening) or
other non work activities that involve
potentially hazardous chemical,
physical, biologic or psychologic
exposures that may account for the
symptoms?
67

Factors
b. Does the patient live near any factories,
waste dump sites, or contaminated sources
of water?
c. Does the patient live with someone who
brings hazardous workplace substances
home on work clothes, shoes, or hair?
68
OCCUPATIONAL DISEASE
WHO has classified occupational diseases into the

following categories :
1. Diseases directly caused by occupation,
e.g. pneumoconiosis.
2. Diseases where an occupation is an etiologic
factor, e.g. bronchogenic carcinoma.
3. Diseases where an occupation is one of the
etiologic factors in a complex situation,
e.g. chronic bronchitis.
4. Diseases where an occupation may aggravate
pre-existing conditions.
69
WHO membedakan empat kategori penyakit akibat

kerja, yaitu :
1. Penyakit yang melulu disebabkan karena
pekerjaan, misalnya pneumokoniosis.
2. Penyakit yang salah satu faktor penyebabnya
adalah pekerjaan, misalnya karsinoma bronkogenik.
3. Penyakit dimana pekerjaan merupakan suatu faktor
penyebab dalam situasi yang kompleks, misalnya
bronkitis kronis.
4. Penyakit dimana pekerjaan dapat memperberat
keadaan yang sudah ada sebelumnya, misalnya
asma.
70
Penyakit Akibat Kerja

Setiap penyakit yang disebabkan oleh pekerjaan
atau lingkungan kerja (pasal 1, Peraturan Menteri
Tenaga Kerja dan Transmigrasi No.PER/01/MEN/1981
tentang Kewajiban Melaporkan Penyakit Akibat Kerja).
Definisi yang digunakan dalam keputusan Menteri
Tenaga Kerja RI No. KEPTS. 333/MEN/1989 tentang
Diagnosis dan Pelaporan Penyakit Akibat Kerja
Merujuk ketentuan PerMen Nakertans No. PER
01/MEN/1981.
71
Jenis PAK
Dalam Keppres No. 22 tahun 1993 terdapat 31
jenis penyakit akibat kerja, 29 dari 31 jenis
penyakit akibat kerja tersebut adalah PAK yang
bersifat international; Penyakit-penyakit ini
mengikuti standar ILO.
Dua jenis penyakit lainnya yaitu penyakit yang
disebabkan oleh paparan suhu udara tinggi atau
rendah (thermal stress) dan penyakit yang
disebabkan oleh bahan kimia lainnya (termasuk
bahan obat) tidak termasuk penyakit akibat kerja.
72
Jenis Penyakit akibat Kerja

Tiga puluh satu jenis (31) jenis PAK sebagaimana
tercantum dalam Lampiran Keppres No. 22 tahun
1993
adalah sebagai berikut :
1. Pneumokoniosis yang disebabkan debu mineral
pembentuk jaringan parut (silikosis,
antrakosilikosis,
asbestosis) dan silikotuberkulosis yang silikosisnya
merupakan faktor utama penyebab cacat dan
kematian.
2. Penyakit paru dan saluran pernapasan
(bronkhopulmoner) yang disebabkan oleh debu
logam
berat.
73

3. Penyakit paru dan saluran pernapasan
(bronkhopulmoner) yang disebabkan oleh
debu kapas, vlas, henep dan sisal (bissinosis).
4. Asma akibat kerja yang disebabkan oleh
penyebab sensitisasi dan zat perangsang
yang dikenal dan berada dalam proses
pekerjaan.
74

5. Alveolitis alergis dengan penyebab dari luar
sebagai akibat penghirupan debu-debu
organik.
6. Penyakit yang disebabkan oleh berilium atau
persenyawaannya yang beracun.
7. Penyakit yang diebabkan oleh kadmium
atau
8. Penyakit yang disebabkan oleh fosfor atau
9. Penyakit yang disebabkan oleh krom atau
75

10. Penyakit yang disebabkan oleh mangan atau
11. Penyakit yang disebabkan oleh arsen atau
12. Penyakit yang disebabkan oleh air raksa
atau persenyawaannya yang beracun.
13. Penyakit yang disebabkan oleh timbal (Pb,
timah
hitam) atau persenyawaannya yang beracun.
14. Penyakit yang disebabkan oleh fluor atau
76

15. Penyakit yang disebabkan oleh karbon
disulfida.
16. Penyakit yang disebabkan oleh derivat
halogen dari persenyawaan hidrokarbon
alifatik atau aromatik yang beracun.
17. Penyakit yang disebabkan oleh benzen atau
homolognya yang beracun.
18. Penyakit yang disebabkan oleh derivat nitro
dan amina dari benzen dan homolognya
yang beracun.
19. Penyakit yang disebabkan oleh
nitrogliserin atau ester asam nitrat lainnya.
77

20. Penyakit yang disebabkan oleh alkohol,
glikol atau keton.
21. Penyakit yang disebabkan oleh gas atau
uap penyebab asfiksia atau keracunan
seperti karbon monoksida, hidrogen
sianida, hidrogen sulfida, atau derivatnya
yangberacun, amoniak, seng, braso dan
nikel.
22. Kelainan pendengaran yang disebabkan
oleh kebisingan.
78

23. Penyakit yang disebabkan oleh getaran
mekanis (kelainan otot, urat, tulang ,
persendian, pembuluh darah tepi atau
saraf tepi).
24. Penyakit yang disebabkan oleh
pekerjaan dalam udara yang bertekanan
lebih.
79

25. Penyakit yang disebabkan oleh radiasi
elektromagnetik dan radiasi yang mengion.
26. Penyakit kulit (dermatosis) yang disebabkan
oleh penyebab fisik, kimiawi atau biologis.
27. Penyakit kulit epitelioma primer yang
disebabkan oleh ter, pitch, bitumen, minyak
mineral, antrasen atau persenyawaan, produk
atau residu dari zat-zat tersebut.
28. Kangker paru atau mesotelioma yang
disebabkan oleh asbes.
80

29. Penyakit infeksi yang disebabkan oleh virus,
bakteri atau parasit yang didapat dalam
suatu pekerjaan yang memiliki risiko
kontaminasi khusus.
30. Penyakit yang disebabkan oleh suhu tinggi
atau rendah atau panas radiasi atau
kelembaban udara tinggi.
31. Penyakit yang disebabkan oleh kimia lainnya
termasuk bahan obat.
81
FAKTOR PENYEBAB PAK
82
Faktor Penyebab PAK

1. Faktor fisik
a. Kebisingan
b. Getaran
c. Radiasi Non-ionisasi (ultraviolet, cahaya
tampak/visible light, inframerah, gelombang
radiofrekwensi/gelombang mikro) dan radiasi
mengion (sinar X, sinar gamma partikel alfa dan
beta)
d. Mikroklimat/thermal stress (heat stress and cold
stress), abnormal pressure (hypo and hyperbaric
environment).
83
Faktor Penyebab PAK

2. Faktor Kimia (gas, uap, fume,mist/kabut,
debu, larutan)
3. Faktor biologis (virus, bakteri, parasit, jamur
dll.)
4. Faktor fisiologis/ergonomi (sikap /cara kerja
yang
salah)
5. Faktor mental psikologis (suasana kerja yang
monoton, hubungan kerja yang tidak/kurang
baik, upah yang tidak memadai, dll.)
84
HEALTH
HAZARDS
Health Hazards
Definition
Examples
Irritants
Inflame living tissue on Sulfur dioxide

contact
Corrosives
Destroy or eating
away living tissue
Phenol, sulfuric acid,

HF, chromic acid,
caustic
Sensitizers
Cause allergic
reaction
Nickel, formaldehyde
Target organ Damage specific

chemicals
organ or system
Tetrachloroethylene
CNS, liver)
86
Health Hazards
Definition
Reproductive
hazards
Mutagens
Change genetic
information in the
sperm or egg
Teratogens
Damage fetus
after
conception
Cancer
Cause or are
suspected or are
suspected of
causing cancer
Examples
Lead and PCBs
Vinyl chloride,
benzene
87
Lungs
Cotton dust
Aluminium dust
Asbestos fiber
Silica
Central
nervous
system
Tetrachloroethane
Mercury
Carbon disulfide
Heart
Chloroform
Liver
Tetrachloroethan
e
Vinyl chloride
Carbon
tetrachloride
Kidneys
Mercury
Methyl
bromide
Uranium
88
CHEMICAL ASSOCIATED
WITH CANCER IN HUMANS (IARC)
LUNG :
Asbestos, Vinyl chloride, CMME,
BCME, Iron oxide (?), Arsenic (?)
SKIN :
Arsenic, PCBs (?),
Soot, Tars,Mineral oils
LIVER :
Vinyl chloride, Arsenic, CCl4
Aflatoxins (?), Oxymetholone
BLOOD :
Benzene
Melphalan
Chloroambucil
Cyclophosphamide (?)
Ethylene oxide (?)
Thiotepa (?)
BRAIN :
Vinyl chloride
GASTROINTESTINAL TRACT :
Asbestos
Ethylene oxide (?)
KIDNEY :
Phenacetin (?)
BLADDER :
4-Aminobiphenyl
Auramine
Magenta
Benzidine
Chlornaphazine
2-Naphthylamine
Soot, Tars, Mineral oils
Cyclophosmide (?)
Phenacetin (?)
89
ASFIKSI
Bilamana kadar oksigen dalam udara
menurun sampai dibawah 16%, maka
seseorang yang mengalami defisiensi
oksigen akan mengeluh pusing, sakit
kepala, telinga mendengung, badan
terasa lemah, sesak napas dan sulit
berkonsentrasi.
90
ASFIKSI
Dibedakan 2 macam asfiksi yaitu
simple asphyxiants dan chemical
asphyxiants.
Kadar normal oksigen dalam udara
atmosfir adalah 20,95%, dan kadar
oksigen minimum yang dibutuhkan
oleh manusia adalah 19,5%.
91
Defisiensi Oksigen
Oxygen deficiency in the confined space

which may be caused by :
a. Slow oxidation reactions of either
organic or inorganic substances.
b. Rapid oxidation (combustion).
c. The dilution of air with inert gas.
d. Absorption by grains, chemicals or soils.
e. Physical activity.
93
Simple Asphyxiants
Simple asphyxiants adalah bahan kimia yang

menyebabkan jaringan tubuh mengalami
kekurangan oksigen (hypoxia) karena
kehadiran bahan kimia tersebut akan
mengencerkan kadar oksigen dalam udara
(tanpa reaksi kimia/without chemical
action) sehingga tekanan parsial oksigen
dalam alveoli menurun.
94
Simple Aspyxiants
Asetilen
Gas argon, neon, helium dan karbon
dioksida (CO2)
Dikloromonofluorometan (Freon 21)
Diklorotetrafluoroetan
Gas metan, etan dan butan.
Liquefied Petroleum Gas (LPG)
Gas hidrogen (H2)
95
Chemical Asphyxiants
Bahan kimia lain seperti gas CO dalam tubuh

akan memblokir pengangkutan oksigen ke
jaringan tubuh atau mengganggu
penggunaan oksigen oleh jaringan tubuh.
Gas CO akan mengikat Hb sehingga fungsi
Hb untuk mengangkut oksigen ke sel-sel
jaringan tubuh terganggu.
96
Gas HCN dalam tubuh akan menghambat
aktivitas enzim cytochrome oxidase
sehingga sel-sel jaringan tidak dapat
menggunakan oksigen yang terbawa
oleh aliran darah.
97
Asetonnitril
Akrilonitril
Karbon monoksida (CO)
Sianida (Kalium atau Natrium Sianida)
Hidrogen Sianida (HCN)
Metilen klorida (dalam tubuh akan
mengalami tranformasi metabolik dan
membentuk karbon monoksida)
98
Airborne Dust
The entry of dust particles into the body

depends on their size and solubility.
Only small particles (less than seven
thousandths of a millimeter in diameter) will
be able to reach the gas exchange area.
This respirable dust (which reaches the
gas exchange area) will either be deposited
there or diffused into the bloodstream,
depending on the solubility of the chemicals.
99
Airborne Dust
Insoluble dust particles are mostly eliminated

by the clearing mechanisms of the lungs.
The larger dust particles are filtered by the
hairs of the nostrils or deposited along the
path from the nose to the air passageways.
They will eventually be transported to the
throat where they will be either swallowed,
or spat or coughed out.
100
Airborne Dust
Dust is dangerous because it can cause :
Lung damage, such bronchitis, emphysema,
pneumoconiosis, asthma, or even cancer.
Damage to the nose and throat, leading to
colds, and other infections, or even nasal
cancer.
Skin damage, leading to dermatitis, ulcers,
and skin cancer.
101
Airborne Dust
Eye damage, including conjunctivitis; and
Internal effects including damage to the brain
and nervous system, blood disorders, stomach
cancer, liver and kidney diseases, or bladder
cancer.
102
Efek Debu
1.
2.
3.
4.
5.
Menyebabkan iritasi pada saluran pernapasan.

Menyebabkan fibrosis paru (pulmonary fibrosis).
Menimbulkan reaksi alergi (occupational asthma).
Menyebabkan reaksi alergi (allergic alveolitis)
Diduga dapat menyebabkan kanker pada saluran
pernapasan/paru.
103
PNOS : particles not otherwise specified

There are many insoluble particles of low
toxicity for which no TLV has been
established.
ACGIH believes that even biologically inert,
insoluble, or poorly soluble particles may
have adverse effects and suggests that
airborne concentration should be kept below
3 mg/m3, (respirable particles), and 10
mg/m3 (inhalable particles), until such time
as a TLV is set for a particular substance.
104
PNOS
Do not have an applicable TLV

Are insoluble or poorly soluble in water (or
preferably, in aqueous lung fluid if data are
available)
Have low toxicity (i.e., are not cytotoxic,
genotoxic, or otherwise chemically reactive
with lung tissue, and do not emit ionizing
radiation, cause immune sensitization, or
cause toxic effects other than by
inflammation or the mechanism of lung
overload).
105
Mineral Dusts
106
PNEUMOCONIOSES
107
Mineral dusts are formed from the rocks,

stones, and ores found in the earths crust.
These dusts are often called inorganic dusts
because they are formed from non-living
materials.
Coal is an unusual case. In occupational
disease studies, it is usually grouped with the
mineral dusts because it behaves as inorganic
dusts do.
108
Pneumoconioses caused by sclerogenous

mineral dusts include : silicosis, asbestosis, and
anthracosilicosis.
Silicosis with pulmonary tuberculosis is also
regarded as a dust-related pneumoconiosis,
when silicosis is an essential factor in causing
the resultant incapacity or death.
109
Dusty lung, or pneumoconiosis, is a
condition caused by the deposit of small

dust particles in the gas exchange areas
of the lung and the reaction of the
tissue to their presence.
Changes in the lungs are extremely
difficult to detect at the early stage, and
deterioration occurs long before such
changes can be detected by X-rays.
110
With pneumoconiosis the capability
of the lungs to absorb oxygen will be

reduced and the victim will develop
shortness of breath during strenuous
activities.
The effect is irreversible. Examples
of substances causing pneumoconiosis
are crystalline silica, asbestos, talc, coal
and beryllium.
111
Non-Fibrotic Pneumoconioses
Aluminium
(powder)
Kaolin
Silika amorf
Talk (non
asbestiform)
Barium dan
persenyawaanny
a
Grafit (alami)
Hematite
Fumes oksida
besi (Fe2O3)
Mika
Oksida timah
putih/stannum
Soapstone
112
Silicosis is a pneumoconiosis caused by
inhalation of crystalline particles of free

silica (silicon dioxide).
Silicosis with tuberculosis refers to
the disease resulting from the
interaction of silicosis with tuberculosis
of the lungs.
113
Free Silica (SiO2)

The main crystalline mineral forms
referred to as free silica (SiO2) are :
Quartz
Tridymite
Cristobalite
114
Occupational Exposure
Hard rock mining

Civil engineering work with hard rock
Stone polishing
Casting, fettling and sandblasting in
foundries
Preparation and removal of refractory linings
to furnaces
Boiler scaling
Ceramic, porcelain and enamel manufacture
115
Mechanism of Action
Retention
The dust particles of 5-15 um in diameter

deposited in the airways are cleared by
mucociliary movement, but particles of 0,5-5 um
in diameter landing in terminal airways or
beyond may be retained.
The dust particles retained in the lungs are taken
up by macrophages (mononuclear phagocytes)
and transported either to the airways and
cleared, or to the lung parenchyma.
116
Mechanism of Action
Most particles below 0,5 um in diameter

remain suspended in the air and are
breathed out.
When the dust-containing cells die, other
cells take up the released particles, but
these too are killed, creating a continuous
low-grade reaction leading to the formation
of localized scars (nodules), which mostly
occur around the terminal airways.
117
Mechanism of Action
Free silica dusts vary in their ability to

cause cell death, and this activity can
be delayed by the presence of other
dusts (e.g., oxides of iron and
aluminium) and chemicals (e.g.,
polyvinylpyrrolidine N-oxide) that affect
the surface of the quartz particles.
118
Elimination
The elimination of quartz particles, especially

when mixed with other dusts, may occur in
the first few days after inhalation via the
bronchi and trachea.
The percentage of the dust retained increases
with :
a. Increase in exposure level
b. Higher past exposure to dust; and
c. The presence of lung diseases (especially
tuberculosis).
119
Acute silicosis is a rapidly progressive disease.

In extreme conditions, breathlessness and dry
cough may develop within a few weeks of
exposure.
Chest tightness and incapacity to work develop
within months, and death due to respiratory
failure or cor pulmonale may occur in 1-3 years.
On examination, restricted chest movement,
cyanosis, and late inspiratory rales are found,
with restrictive lung function abnormality and
reduced gas transfer.
120
Silicosis
This occurs most frequently in the upper and

middle zones of the lungs and is seen on the
X-ray as irregular shadowing with coalescence
and calcification. The calcification of enlarged
hilar nodes is also common.
The early stages of silicosis are as a rule not
accompanied by any symptoms or signs of
respiratory disease. Also, the basic ventilatory
lung function test remain with the normal
physiological range.
121
Silicosis
In more advanced stages, dyspnea on
exercise develops.
Because of insidious onset, the
dyspnoeic symptoms may be
attributed to aging; X-rays are
therefore a relatively more specific
method of detection.
122
Silicosis (Continued)
The coalescence of shadows is

accompanied by more rapidly progressive
breathlessness during exercise and by
depressed respiratory function, which is
mainly restrictive in type.
Bronchitic symptoms, e.g., cough and
phlegm due to the deposition of larger dust
particles in the airways are less important
and sometimes reversible.
123
Workers exposed to silica are at an

increased risk of tuberculosis, a risk that is
substantially and permanently increased once
X-ray changes are manifest.
The risk increases with severity of silicosis, and
factors favorable for spreading tuberculosis
include, for example, crowded working
conditions, poor nutrition, and a high
prevalence of infection in the community.
124
Silicosis With Tuberculosis (Continued)

It is supposed that increased susceptibility of
silicosis patients to lung tuberculosis is due to
the damage caused by the dust to
macrophages and to the lymphatic and
immune systems, which normally protect
against pulmonary tuberculosis.
The suspicion of tuberculosis in silicosis
should arise whenever there is a sudden
increase in symptoms or X-ray changes, fever,
loss of weight, or haemoptysis.
125
Silicosis With Tuberculosis (Continued)

The progression of X-ray changes continues to
be more rapid even when the infection is
controlled.
The most reliable index of diagnosis or cure is
the culture of micro bacteria in sputum; other
indices are less reliable.
Previous tuberculosis, treated or not ,
probably increases the risk and severity of
silicosis.
126
What Is Asbestos ?
Asbestos is a soft mineral rock.

Asbestos is made of millions of light,
indestructible fibers that make it a valuable
but hazardous material.
There are three main types of asbestos that
you find at work : crocidolite (blue
asbestos); amosite (brown asbestos); and
chrysotile (white asbestos).
127
Why is Asbestos Dangerous ?
The tiny, indestructible, often invisible

fibers that make asbestos so useful are
harmful to the delicate cells in the human
body when they are inhale.
The main diseases caused by asbestos
dust are : asbestosis, heart failure,
mesothelioma, lung cancer and other
cancers.
128
Asbestosis
A type of pneumoconiosis (Greek for dust in

the lungs) caused by accumulation of dustlungs scarred and shrunken, increasing
breathlessness and paint in chest.
The disease can get worse even if the sufferers
are no longer exposed to asbestos dust.
Sufferers often die from the additional strain
on the heart caused by stiff lungs.
129
Lung Cancer
The difference in risk depends on sex
(women face less risk than men) and on
whether a person smokes.
Given a US urban population of 180
million people, this risk estimate
translates into 1800 to 52.200 expected
cancer from asbestos.
130
Expected Cancers per 100.000 People

Group
Medium
exposure
(0,0004
fiber/cm3)
High
exposure(0,002
fiber/cm3)
Lung cancer
Male smokers
29,2
146
Female smokers
10,5
52,4
Male nonsmokers
2,7
13,2
Female nonsmokers
1,4
6,8
Mesothelioma,
All groups
15,6
78
131
Mesothelioma
A cancer of the lining of the chest
cavity and less frequently the lining of
the abdominal cavity.
It can not be cured and leads to early
death (within 12 months of diagnosis).
132
Mesothelioma
Mesotheliomas are a group of rare human

cancers caused almost exclusively by
exposure to asbestos.
These cancers occur in the membranes
(mesothelia) that line body body cavities.
Mesotheliomas can occur in the lung (pleural
mesothelioma) and in the abdomen
(peritoneal mesothelioma).
133
Asestos and Tobacco Smoke
Asbestos and tobacco smoke have a strong

synergistic interaction in producing lung
cancer;
Asbestos exposure appears to multiply by a

factor of 5 rather than simply adding to the
underlying lung cancer risk from smoking.
Most people who develop lung cancer die

from it within 2 years of diagnosis.
134
Threshold Limit Values
All forms of asbestos :

0,1 fiber /cc
Notation
:
A1 (confirmed
Critical effects
human
carcinogen)
: Asbestosis,
cancer
135
Organic Dusts
136
Organic dusts are derived from living

materials ---- plants, animals,
microorganisms ----- and from such natural
products as wood and leather.
Organic dusts are generated during the
harvesting, storage, transportation, and
processing (milling, chopping, spinning,
sawing) of plant products.
These products include cereal grains, coffee
beans, paprika, cotton, flax, and timber.
137
Animal and poultry husbandry produces dusts

consisting of animal hair and dander, bird feathers,
and droppings.
Wood working and leather working entail
considerable exposure to organic dusts.
All these dusts are recognized causes of lung
disease.
138
Chemical Dusts
In addition to the naturally occurring mineral

and organic dusts provided by nature, humans
have invented many of their own.
An increasing number of synthetic chemicals
are used in industries, business, agriculture,
and the home.
Many of these synthetic chemicals are in
powder form ---- bleaching powder, catalysts,
pesticides, dyes ------ and their dust may cause
disease if inhaled.
139
Non Specific Irritation

Vegetable dusts
Other effects
Sisal
Jute
Hard hemp
Indian hemp
Manila hemp
Kapok
Coir (coconut husk)
Byssinosis
Possibly
occupational
asthma
140
Non Specific Irritation

Grain dusts
Corn, wheat,
barley
Rice
Tea
Coffee
Other effects
Occupational asthma
and allergic alveolitis
Occupational asthma
Occupational asthma
Occupational asthma
141
Debu Penyebab Asma

Jenis debu
Pekerja yang
terpapar
Efek lain
Gandum, padipadian dan hasil

olahannya
Petani, penggiling COPD, dan

extrinsic allergic
(millers)
alveolitis
Debu kayu (red

cedar, iroko)
Penebang kayu,
tukang kayu
COPD dan
extrinsic allergic
alveolitis
Teh
Pencampur dan
pengepak
Kemungkinan
COPD
Tembakau
Pemotong dan
pencampur
Kemungkinan
COPD
142
Debu Penyebab Asma

1. Kobal (fume dan debu)
2.
3.
4.
5.
6.
7.
8.
9.
Debu gandum
Nikel (logam)
Garam platina
Tungten carbide
Detergent (enzymatic detergent)
MDI (methylene diphenyl isocyanate)
Debu kayu (wood pulp/dust)
Toluene isocyanate (TDI)
143
Occupational Asthma
1. Biji-bijian (grains), debu tepung (fluor), getah
tanaman (gums).
2. Serangga (insects), produk binatang (animal
products), jamur (fungi) dll.
3. Logam seperti nikel dan kobal.
4. Obat-obatan (drugs), isosianat (isocyanates).
5. Debu kayu dan debu tumbuh-tumbuan
lainnya (vegetable dusts).
144
Hypersensitivity pneumonitis
(allergic alveolitis) results from the
bodys reaction to inhaled antigens.
The antigens come from molds, other
microorganisms, and animal protein.
Farmers lung is the best known
example of hypersensitivity
pneumonitis, a disease caused by fine
organic dust that is inhaled deep into
the lungs smaller airways.
145
Farmers lung is caused by mold on hay,

straw, grains, and other organic materials found
on farms.
Other dusts known to be involved in
hypersensitivity pneumonitis include moldy
sugar cane and barley, maple bark, cork, animal
hair, bird feathers and droppings, mushroom
compost, coffee beans, and paprika. Often the
disease is named for the occupation mushroom
workers lung, paprika - splitters lung.
146
Hypersensitivity Pneumonitis
The symptoms of hypersensitivity

pneumonitis begin some hours after exposure
to the offending dust.
The patient fells tired and short of breath,
and has a dry cough, fever, and chills.
Inside his lungs, the alveoli are inflamed ,
inudated (dibanjiri) by white blood cells and
sometimes filled with fluid.
His symptoms may last from one to 10 days
147
TYPES OF EXTRINSIC ALLERGIC ALVEOLITIS

Type
Farmers lung
Exposure
to
Allergen
Moldy hay
Micropolyspora
faeni,
thermoactinomyces
vulgaris
Bagassosis
Moldy sugar
cane
Thermoactinomyces
sacchari
Suberosis
Moldy cork
Penicillium
frequentants
Bird faciers
lung
Malt workers
Droppings
and
feathers
Moldy barley
Avian protein
Aspergillus clavatus
148
Characteristics
Extrinsic allergic
Asthma (type I)
Extrinsic allergic
alveolitis (type III)
Predisposing
factors
Atopy
None known
Region affected
Conducting system
of the lung (bronchi
to terminal
bronchioles)
Acini, respiratory
bronchioles and
alveoli
Histology
Mucus plugging,
bronchial edema
and eosinophilic
infiltration
Granulomatous
pneumonitis,
occasionally
undergoing
organization and
leading to
interstitial fibrosis
149
Pulmonary Responses
to Inhalation of Organic Particles
Characteristics
Extrinsic allergic
Asthma (type I)
Onset of
symptoms
Immediate
Systemic reaction
none
Physical signs
Wheezes
(ronchi)
Extrinsic allergic
alveolitis (type III)
4-6 hours
Usual and
accompanied
by fever
Crackles
(crepitation)
150
Debu Penyebab Asma

Jenis debu
Gandum, padipadian dan hasil
olahannya
Pekerja yang
terpapar
Petani,
penggiling
(millers)
Efek lain
COPD, dan
extrinsic allergic
alveolitis
Debu kayu (red

cedar, iroko)
Penebang kayu,
tukang kayu
COPD dan
extrinsic allergic
alveolitis
Teh
Pencampur dan
pengepak
Kemungkinan
COPD
Tembakau
Pemotong dan
pencampur
Kemungkinan
COPD
151
FAKTOR FISIK
152
KEBISINGAN
153
It is customary to call any undesirable

sound noise.
The disturbing effects of noise depend both
on the intensity and the frequency of the
tones. For example, higher frequencies
are more disturbing than low ones.
Pure tones are more disturbing than a
sound made up of many tones.
154
Kebisingan (Noise)
Kebisingan adalah suara yang tidak dikehendaki
(unwanted/undesired sound).
Pemaparan kebisingan yang berulang dan
menahun pada intensitas yang tinggi dapat
menyebabkan tuli saraf yang sulit disembuhkan.
Ketulian akibat paparan kebisingan
(NIHL=Noise-Induced Hearing Loss) umumnya
terjadi setelah 10 tahun paparan atau lebih.
155
Kebisingan
Faktor-faktor yang mempengaruhi terjadinya
NIHL (Noise-Induced Hearing Loss) :
1. Lamanya pemaparan (duration of exposure)
2. Tingkat intensitas suara (sound intensity
level)
3. Spektrum atau komposisi frekwensi suara
(Noise spektrum)
4. Frekuensi/pola pemaparan (frequency or
temporal pattern of noise exposure)
5. Kerentanan individu (individual
susceptibility)
156
NAB Kebisingan
Noise level (dBA)
Exposure Time
(hours)
Daily Noise Dose
85
88
88
91
91
94
94
97
0,5
97
157
Efek Kebisingan
Trauma akustik
Ketulian sementara (temporary threshold
shift/TTS)
Ketulian permanen (permanen threshold
shift/PTS)
158
Trauma Akustik
Gangguan pendengaran yang
disebabkan oleh pemaparan tunggal

(single exposure) terhadap intensitas
kebisingan yang sangat tinggi dan
terjadi secara tiba-tiba.
Contoh : suara ledakan bom.
159
Temporary Threshold Shift

(TTS)
Bilamana seseorang masuk ke suatu tempat
kerja yang bising, maka mula-mula orang

tersebut akan merasa terganggu dengan adanya
kebisingan tadi.
Namun, setelah beberapa jam berada di tempat
kerja tersebut, orang yang bersangkutan merasa
tidak begitu terganggu lagi atau ia merasa
bahwa suara tadi tidak lagi sekeras semula.,
atau dengan kata lain orang tersebut telah
mengalami ketulian.
160
Temporary Threshold Shift

Bilamana orang tersebut keluar dari tempat
kerja yang bising, daya dengarnya sedikit

demi sedikit akan pulih kembali seperti
semula.
Gangguan pendengaran yang dialami oleh
orang tersebut sifatnya sementara
(Temporary Threshold Shift).
Waktu yang diperlukan untuk beberapa menit
sampai beberapa hari (3 7 hari), namun
paling lama tidak lebih dari 10 hari (ISO).
161
Faktor-faktor yang Mempengaruhi TTS

Tingkat intensitas suara
Lamanya pemajanan
Karakteridtik dari spektrum kebisingan
(frekuensi kebisingan)
Temporal pattern dari pemajanan
(continuous atau intermittent)
Kerentanan individu
Waktu pemeriksaan pendengaran
dilakukan, yakni interval antara bebas
bising dan pemeriksaan.
162
Permanent Threshold Shift

(PTS)
Bilamana seseorang pekerja mengalami
TTS
dan kemudian terpapar kembali sebelum
pemulihan secara lengkap terjadi, maka
terjadi akumulasi sisa ketulian TTS).
Bila hal ini berlangsung secara berulang
dan
menahun, sifat ketulian akan berubah
menjadi permanen.
163
Noise-Induced Hearing Loss

PTS sering pula disebut NIHL (Noise Induced
Hearing Loss) dan NIHL umumnya terjadi setelah
pemparan 10 tahun atau lebih, dan karena PTS ini
terjadinya secara perlahan-lahan, maka biasanya
penderita tidak menyadari bahwa dirinya telah
menderita ketulian.
Pada stadium dini, ketulian akibat kebisingan
biasanya terjadi pada frekuensi 3 6 kHz, dan
kenaikan ambang pendengaran (Hearing
Threshold Shift) paling besar terjadi pada
frekuensi 4000 Hz.
164
Noise-Induced
Loss
Bilamana
ketulian menjadi Hearing
lebih parah karena
pemajanan yang berulang dan menahun, maka
Hearing loss atau kehilangan pendengaran tidak
saja akan terjadi pada frekuensi 4000 Hz, tetapi
juga terjadi pada frekuensi dibawah dan diatas
4000 Hz.
Bilamana kenaikan ambang pendengaran terjadi
Pada frekuensi pembicaraan yakni 500, 1000 dan
2000 Hz, maka komunikasi pada stadium ini akan
menjadi sulit.
165
HEARING PROTECTION DEVICES
166
167
Suhu kering (Dry-bulb temperature)

Adalah suhu udara yang ditunjukkan oleh suatu
termometer yang akurat setelah panas radiasi
yang dapat mempengaruhi hasil pembacaan
dikoreksi.
Suhu basah (Wet-bulb temperature)
Adalah suhu yang menunjukkan bahwa udara
telah jenuh dengan uap air.
168
Suhu Kering & Suhu Basah

Suhu kering (Dry-bulb temperature)
Adalah suhu udara yang ditunjukkan oleh suatu
termometer yang akurat setelah panas radiasi
yang dapat mempengaruhi hasil pembacaan
dikoreksi.
Suhu basah (Wet-bulb temperature)
Adalah suhu yang menunjukkan bahwa udara
telah jenuh dengan uap air.
169
Kelembaban
Kelembaban (humidity)
Kelembaban atau kelembaban udara dapat
dibedakan menjadi: kelembaban absolut dan
kelembab nisbi (relative humidity).
Kelembaban absolut adalah berat uap air
per unit volume udara (misalnya sekian gram
uap air dalam satu liter udara).
170
Kelembaban Nisbi
Kelembaban nisbi/relatif adalah rasio
dari banyaknya uap air dalam udara pada
suatu temperatur terhadap banyaknya
uap air pada saat udara telah jenuh
dengan uap air pada temperatur tersebut
(dinyatakan dalam %).
171
Iklim Kerja
Hasil perpaduan antara suhu, kelembaban,
kecepatan gerakan udara dan panas
radiasi dengan tingkat pengeluaran panas
dari tubuh tenaga kerja sebagai akibat
pekerjaannya. (Heat stress is the load on
the man and heat strain is the effect of
the load).
172
TLVs of Heat Stress

Workers should not be permitted to
continue their work when their deep
body temperature exceeds 38oC.
173
Permissible Heat Exposure TLV WBGT

Work-rest
regimen
Light work
load
Moderate
work load
Heavy work
load
Continuous
work
30.0 oC
26.7 oC
25.0 oC
75% work
25% rest,
each hour
30.6 oC
28.0 oC
25.9 oC
50% work
50% rest,
each hour
31.4 oC
29.4 oC
27.9 oC
25% work
75% rest,
each hour
32.2 oC
31.1 oC
30.0 oC
174
Efek Tekanan Panas

Heat stress adalah besarnya beban pada
manusia, sedangkan heat strain adalah efek
dari beban tersebut. Beberapa index yang
digunakan untuk menentukan besarnya heat
strain (respon fisiologis terhadap panas)
antara lain adalah banyaknya keringat yang
dihasilkan, banyaknya keringat yang
menguap, denyut jantung dan suhu tubuh.
175
Heat stroke
Kulit kering, panas, kemerahan (mottled skin)

dan cyanosis (berwarna kebiruan);
Suhu tubuh meningkat sampai 40,5 o C atau
lebih;
Kesadaran penderita menurun, gangguan
fungsi mental, kejang, dan bila pengobatan
terlambat penderita akan meninggal.
Penyebab heat stroke : kegagalan pusat
pengatur suhu tubuh
176
Heat Hyperpyrexia
Suhu tubuh meningkat dan biasanya tidak

terlalu tinggi seperti yang dialami oleh
penderita heat stroke;
Kelainan otak yang tidak begitu berat dan
penderita masih dapat berkeringat.
Penyebab hyperpyrexia adalah kegagalan
sebagian (partial failure) dari pusat
pengatur suhu tubuh.
177
Heat Cramps (Kejang panas)
Kejang pada otot lengan, tungkai bawah

atau perut (abdomen) pada saat atau
sesudah kerja;
Penyebab : Tubuh kehilangan garam
(elektrolit) akibat pengeluaran keringat yang
berlebihan, atau karena terjadinya
ketidakseimbangan elektrolit (electrolyte
imbalance) akibat minum air yang
berlebihan tanpa diberi garam(sesudah kerja
berat) sehingga air akan masuk kedalam
otot dan kemudian menyebabkan kejang
pada otot tersebut.
178
Heat rash (miliaria)
Timbul vesicula berwarna kemerahan pada

kulit dan biasanya ditemukan pada daerah
punggung, leher dan dada;
Penyebab : penyumbatan saluran kelenjar

keringat oleh keringat, dan kelenjar tersebut
kemudian mengalami peradangan/inflamasi.
179
Heat Exhaustion
Kelelahan, mual, sakit kepala/pusing;

Kulit basah, terasa dingin, dan pucat;
Denyut nadi meningkat, tekanan darah menurun,
penderita akan pingsan bila berdiri;
Suhu mulut dapat menurun atau normal, namun
suhu dubur biasanya meningkat sampai 37,538,5o C;
Produksi urin akan menurun, dan kadar garam
klor dalam urin dapat mencapat 3 g/l;
180
Penyebab Heat Exhaustion
Dehidrasi akibat defisiensi air dan atau

garam (NaCl);
Menurunnya volume darah;
Gangguan sirkulasi darah ke organ tubuh
sebagai akibat meningkatnya aliran darah
ke kulit dan otot.
181
Heat syncope
Penderita pingsan pada saat berdiri tegap
dan tidak bergerak dibawah terik
matahari;
Penyebab : penimbunan darah di
pembuluh
darah kulit pada tubuh bagian bawah.
182
Heat Disorders
A classification of disorders caused by
exposure to high levels of environmental
heat is as follows :
Systemic disorders : heat stroke
(hyperpyrexia), heat exhaustion (from
circulatory deficiency; heat syncope),
water deficiency, salt deficiency, heat
cramps, or sweating deficiency.
183
Heat Disorders
Continued .
Skin disorders : prickly heat (miliaria
rubra), cancer of the skin (rodent ulcer).
Psychoneurotic disorders : mild
chronic (tropical) heat fatigue, acute loss
of emotional control.
184
Heat-Related Illnesses
Psychoneurotic disorders ---- tropical
fatigue. Chronic effects upon Europeans
of working for long periods in the tropics
have been reported.
Loss of motivation, lassitude,
irritability, sleeplessness appear to
constitute the symptoms of a condition
for which little physiological evidence has
been found.
185
Heat Rash
Prickly heat, painful itching may occur
if skin is constantly wet with sweat
and sweat glands become plugged.
Worker needs to allow time to dry off

in cold area, bathe or use drying
powder.
186
Heat Cramps
Painful muscle spasms of arms and
legs, resulting from electrolyte
imbalance perhaps from drinking large
volumes of water after heavy work.
Salt intake need to be adequate.
187
Heat Cramps
Heat cramps often occur in conjunction with
conditions of salt depletion when levels of
sodium chloride (NaCl) circulating in the
blood fall below a critical level.
The attacks of severe painful spasms in limb
and abdominal muscles may last for several
hours, days, or even weeks.
188
Fainting/Heat Syncope
Fainting results from insufficient blood
flow to the brain.

Blood vessels expand as blood flow
increases, more goes to the surfaces
rather than brain and gravity can
cause pooling of blood in lower parts of
the body.
Lying the worker down will result in
complete recovery.
189
Heat Exhaustion
Heat exhaustion occurs when body losses
too much fluid, or too much salt or both.
Worker becomes dry in mouth, thirsty,
weak, fatigued.
Remove with rest, administer fluids .
Ensure workers are acclimatized, with
ability to take water regularly during work.
190
Heat Stroke
Result in hot dry skin, mottled or cyanotic
(bluish).
Can be the result of several causes including
extensive overexertion, loss of fluids, cardiac
disease.
The body fails to sweat, so evaporative
cooling does not function.
Body temperature rises uncontrollably,
accompanied by convulsions, loss of
consciousness.
191
Dehydration
A mild thirst reflects uncorrected water loss
of
less than 5% of body weight.
There may be increases in pulse rate and body
temperature. A decrease in output of urine
(oliguria), loss of working efficiency,
complaints
of restlessness, irritability, lassitude or
drowsiness and of thirst when uncorrected
water loss amounts to 5-8% of body weight.
192
Dehydration
No work can be performed by patients
with a water loss deficit of about 10%
of body weight.
Death occurs when depletion of blood
volume (oligaemic shock) results from
water loss in excess of 15% of body
weight.
193
Drinking Water
Liquids should be taken in small quantities and
often from the start of exposure to high

temperatures : 100 to 150 ml of water every
15 to 20 minutes.
The quantities to be drink should be calculated
on the basis of the fluid loss, since the thirst
mechanism does not at all furnish an
appropriate
basis for compensating the important factor,
which is fluid loss.
194
Drinks
Recommended drinks are plain (non-
carbonated) cool water (9-12 oC); Cool

lemon tea, well diluted fluid juice, etc.
Carbonated drinks, undiluted fluid juice,
milk and especially any alcoholic drinks
should be forbidden.
195
Drinks
Intolerance to high temperature due to
dehydration disappears completely when, for

example, miners exposed to a wet-bulb
temperature of more than 29 oC drink at least
3 liters of water per shift;
Their capacity for work is even increased by
the addition of 100 g of sugar to the drinking

water distributed during the working day.
196
Alcoholic Drinks
Binge (pesta minum minuman keras) type
alcohol consumption results in the production

of quantities of dilute urine.
The individual is now much more susceptible to
dehydration working in a hot environment, and
therefore to heat stroke.
As a CNS depressant, alcohol interferes with
heat adaptation.
197
Food
The intake of fatty foodstuffs should
be reduced.
The administration of additional salt is
only justified in the case of
unacclimatized workers who are newly
assigned to a hot workplace.
198
Control Measures
Restrict overtime work in hot

environments.
Provide specialized vortex air-cooled or
ice suits for some continuous demand
tasks.
Training and selection of workers.
199
Control Measures
Supervisors and workers should be
trained in recognition of various heat
illnesses.
Workers to be alerted to effects of
drugs,
alcohol, obesity on heat illnesses.
200
201
Getaran
Getaran mekanis (non acoustic vibration)
dapat
dibedakan menjadi :
Whole body vibration (getaran seluruh
tubuh). Frekuensi getaran : 1-80 Hz.
Segmental vibration/tool-hand vibration.
Frekuensi getaran setempat : 8 Hz 1 kHz.
202
Efek Getaran Seluruh Tubuh

1. Perubahan pada struktur tulang belakang
(osteoarthritis)
2. Gangguan pencernaan (sekresi dan motilitas)
3. Prostatitis
4. Gangguan pada kecepatan konduksi saraf
(nerve conduction velocity).
203
Efek Getaran Seluruh

Tubuh
5. Motion sickness (gangguan pada sistem
keseimbangan)
6. Gangguan penglihatan
7. Kerusakan pada sistem reproduksi
wanita (female reproductive damage)
204
Whole Body Vibration
Contoh : mengemudi traktor,

penumpang/ awak kapal yang
sedang berlayar di lautan yang
gelombangnya tinggi.
205
SOURCES OF VIBRATION
206
Terdapat berbagai faktor yang perlu

diperhatikan dalam menilai efek getaran
pada manusia yaitu:
Karakteristik fisik dari frekuensi dan intensitas
getaran
Tipe dari sumber getaran
Lamanya pemajanan
Arah getaran
Posisi tubuh
Kerentanan individu
Faktor lingkungan misalnya suhu udara,
kebisingan, beban kerja dll.
207

Pada frekuensi antara 4 dan 12 Hertz, getaran
seluruh tubuh dapat menyebabkan kerusakan
pada sistim otot dan tulang.
Getaran akan diteruskan ke tulang-tulang dan
sendi-sendi dan hal ini akan menimbulkan
perubahan gerakan ujung-ujung tulang pada
tulang rawan yang terdapat pada sendi-sendi
terutama sendi tulang belakang.
208

Lanjutan .
Getaran dari tulang ini akan menyebabkan
kerusakan pada sel-sel tulang rawan, dan
kemudian akan terjadi reaksi peradangan
pada
tulang rawan yang bersangkutan.
Setelah pemaparan yang berulang dan
menahun, getaran seluruh tubuh akan
menyebabkan kerusakan yang permanen
pada
sendi (arthritis).
209
Efek Getaran Seluruh

Tubuh
Lanjutan ..
Sebagai komplikasi dari kerusakan tulang rawan
ini akan terjadi slipped disc yaitu suatu
keadaan dimana discus intervertebralis yang
terdapat pada sendi-sendi tulang belakang yang
berfungsi sebagai bantalan dapat terlepas dan
keluar dari tempatnya semula. Slipped disc
ini akan menyebabkan rasa sakit pada pinggang
(lumbago) karena tekanan discus Intervertebralis pada syaraf-syaraf medula spinalis.
210

Frekuensi getaran yang paling sering
menyebabkan
kerusakan pada tulang-tulang rawan sendi
tulang
belakang berkisar antara 4 sampai 5 Hertz.
Selain low back pain, pemaparan whole body
vibration sering pula menyebabkan rasa
ketidaknyamanan pada perut dan hematuria.
Pada binatang percobaan, pemaparan whole
body
vibration pada frekuensi 5 20 Hertz dan
intensitas
getaran yang sangat tinggi dapat menimbulkan
211
HEALTH EFFECTS
(WHOLE BODY)
Effects to the lower
back vertebrates
and the nervous
system that
surrounds it.
Other
Health
Effects.
212
Pengendalian Getaran
1. Engineering Control
Tingkat getaran sering dapat direduksi
melalui berbagai peralatan teknis
misalnya dengan pemasangan vibration
isolator (pegas/springs atau bantalan
kompresi diatas mesin-mesin yang akan
diletakkan.
213
Pengendalian Getaran
2.
Pemeliharaan/perawatan mesin yang

baik
Perawatan mesin perlu dilakukan secara
berkala, dan bilamana mungkin
pemantauan
kondisi mesin dengan alat ukur getaran
(sebagai indikator mesin) juga dilakukan.
Bagian-bagian mesin yang rusak (aus)
perlu
segera diganti.
214
3. Substitusi
Substitusi alat-alat/mesin-mesin atau proses
yang menimbulkan intensitas getaran yang
tinggi dengan alat-alat/mesin-mesin yang
tingkat getarannya rendah.
4. Penempatan alat-alat
Alat-alat hendaknya ditempatkan/diletakkan
diatas permukaan (dinding, lantai dan langitlangit) yang tebal dan padat (massive dan rigid),
dan sejauh mungkin dari daerah kritis.
215
5. Modifikasi
Modifikasi karakteristik kecepatan dan gerakan
alat-alat/mesin-mesin sedemikian rupa sehingga
frekuensi dan karakteristik dari energi getaran
akan dimodifikasi.
6. Alat pelindung diri
Khusus bagi pekerja yang terpapar segmental
vibration dan bekerja ditempat-tempat kerja yang
dingin, pekerja tersebut hendaknya memakai
sarung tangan dari kulit pada waktu kerja.
216
7. Pemeriksaan kesehatan
Pemeriksaan kesehatan baik sebelum kerja, secara
berkala dan khusus perlu dilakukan. Mereka yang
menderita kelainan pembuluh darah dan jantung
(cardiovascular), arthritis, kelainan syaraf, diabetes
mellitus dan lain-lain perlu dihindarkan dari
pemajanan getaran.
8. Kontrol administratif
Pengendalian secara administratif bertujuan untuk
mengurangi waktu pemajanan, dan cara
pengendalian ini dapat dilakukan misalnya dengan
job rotation.
217
9. Pelatihan dan pendidikan

Penyuluhan, latihan atau pendidikan tentang
kesehatan dan keselamatan kerja pada
umumnya, dan mengenai pengaruh getaran
serta cara-cara pencegahannya pada
khususnya, perlu dilakukan secara berkala dan
berkesinambungan.
218
Hand-Arm Vibration (HAV)
HAV is vibration transmitted from work

processes into workers hands and arms. It
can be caused by operating hand-held power
tools such as road breakers, hand-guided
equipment such as lawn mowers or by
holding materials being processed by
machines such as pedestal grinders.
219
What injuries can HAV cause?
Regular exposure to HAV can cause a range

of permanent injuries to your hands and arms
that are known as hand-arm vibration
syndrome. The injuries can include damage to
the following:
220
What
injuries
can
HAV
cause?
Blood Circulatory System (vibration white

finger)
The systems of VWF are usually set off when
your hands or body get cold or wet. The first
sign is often an occasional attack when your
fingertips become white.
During an attack your fingers may also become
numb and you may get a pins & needles
feeling. An attack may end with the whiteness
in your fingers changing to a deep red flush
that is often very painful.
221
What
injuries can HAV cause?
Sensory Nerve Damage

Damage to the nerves in your fingers will
mean that your senses of touch and
temperature are reduced which may
cause permanent numbness or tingling in
your fingers.
Damage to Muscle, Bones & Joints

You may notice loss of strength in your
hands and pain in your wrists and
arms.
222
Health Effects
Vascular and circulation problems
Neurolgical
Muscular disorders
Others
223
Efek Getaran Setempat

1. Vibration White Finger (VWF) atau
Raynaud syndrome.
2. Degenerasi saraf dengan akibat hilangnya
rasa terhadap panas atau sentuhan (loss
of senses of touch and heat).
3. Dekalsifikasi tulang-tulang pergelangan
tangan (decalsification of carpal tunnel).
4. Atrofi otot dan peradangan pada tendon
otot dan sinovia (tenosynovitis).
224
Symptoms Advanced
Stages
White or Blanched
Finger Tips
Aggravated by cold
Mistaken for frostbite
Few minutes initially
With Continued
Exposure
Blanching spreads
Attacks increase in
Frequency
Intensity
Duration
225
Symptoms Latter stages

Occur in all seasons
On and off job
Triggered by
Cold
Vibrating objects
Nicotine
Severe Cases
Gangrene
Amputation
226
Stockholm HAVS Classification System

(Vascular Assessment)
Stage
Grade
Description
---------
No attacks
1V
Mild
Occasional attacks affecting only one

or more fingers
2V
Moderate
Occasional attacks affecting distal

and middle phalanges (rarely also
proximal) of one or more fingers
3V
Severe
Frequent attacks affecting ALL

phalanges of most fingers
4V
Very
Severe
As in Stage 3, with trophic skin

changes in the finger tips
227
Stockholm HAVS Classification System

(Sensorineural Assessment)
Stage
Symptoms
0SN
Exposed to vibration but no symptoms
1SN
Intermittent numbness, with or without

tingling
2SN
Intermittent or persistent numbness,

reducing sensory perception
3SN
Intermittent or persistent numbness,

reducing tactile discrimination and/or
manipulative dexterity
228
Vascular Disorders
Muscle
Normal
Artery
Normal
flow
Damage
Artery
Flow
Restriction
229
HAND-ARM VIBRATION
230
Hand Arm Vibration

Exposure
231
Hand Arm Vibration

Exposure
232
233
NON-IONISING RADIATION
234
RADIATION
Radiation is the process whereby the
energy is propagated through space or
matter in the form of waves.
Radiation is the transmission of energy
by means of electromagnetic wave
(Joseph Salvato, 1982)
235
Electromagnetic Spectrum
Name
1. Gamma rays
2. X rays
3. Optical
a. Ultraviolet
b. Visible (400-760
nm)
c. Infrared
*Soft X rays
*Hard X rays
Photon energy
107 eV
100 -106 eV
10 eV
1 eV
10-1 10-2 eV
100 eV
1000 1.000.000 eV
236
4. Radiofrequency
(RF)
a. Millimetric
microwaves
b. Microwaves
c. Radiofrequency
5. Subradiofrequency
ELF
6. DC (Direct Current)
Photon energy
10-3 10-4 eV
10-5 10-6 eV
10-7 10-10 eV
10-11 10-13 eV
0
237
Frequency (Hz)
1. 3x1021 (gamma
rays)
2. 3x1020 3x1016
(X rays)
3. 3x1015 3x1012
(optical radiation)
Wavelength
(meter)
10-13
10-8 10-12
10-7 10-4
238
Radiasi dapat dibedakan menjadi

:
Radiasi pengion, contoh sinar X dan Gama
Radiasi yang tidak mengion, contoh

ultraviolet, infra merah, cahaya tampak
(visible light) dan gelombang mikro.
239
Batasan
Radiasi adalah suatu proses dimana energi
dirambatkan/ditransmisikan melalui suatu ruang
atau zat dalam bentuk gelombang (Josep A.
Salvato,1982).
240
Radiasi Ultraviolet
Matahari merupakan sumber alami radiasi
ultraviolet (UV).
Dua per tiga dari ultra violet yang secara
biologis adalah aktif terdapat dalam cahaya
matahari yaitu antara jam 10.00 mdan
14.00, dan radiasi ini akan lebih banyak
ditemukan pada daerah dimana tekanan
udara atmosfirnya rendah (daerah
pegunungan).
241
Radiasi Ultraviolet
Radiasi ultraviolet dari cahaya matahari yang
mengenai bumi akan disebarkan ke semua
arah, dan banyaknya radiasi yang
disebabrkan kurang lebih adalah 50 %
sehingga topi atau payung hanya dapat
mereduksi intensitas radiasi paling banyak
sebesar 50 %. Pasir, salju dan es adalah
reflektor yang efektif untuk radiasi ultraviolet
Contoh sumber radiasi buatan adalah lampu
merkuri bertekanan rendah atau tinggi,
lampu pembunuh hama (germicidal lamps)
dan pada pengelasan terutama las listrik.
242
Efek Radiasi
Ultraviolet
Peradangan kornea (photokeratitis)
Peradangan selaput lendir mata
(conjunctivitis)
Perubahan pigmentasi kulit (hipo/hiper
pigmentasi
kulit)
Luka bakar pada kulit (skin/sun burn)
Keratosis (solar keratosis)
Solar elastosis (premature ageing of skin)
Kanker kulit (UV-B)
243
Radiasi Infra Merah

Sebagai sumber adalah matahari,
semua benda yang berpijar atau
logam yang dipanaskan, lampulampu pijar/filament, tungkutungku/dapur pijar, bunga api yang
dihasilkan pada pengelasan listrik
dan lain-lain.
244
Pengaruh radiasi infra merah terutama

adalah pada mata dan kulit.
Pada mata, radiasi infra merah dapat
menyebabkan katarak lensa setelah
pemajanan 10 -15 tahun pada intensitas
radiasi 0,08 0 4 Wcm-2 dan tingkat
pemajanan ini dapat ditemukan di tempattempat kerja.
245
Pada kulit, radiasi infra merah akan

menyebabkan vasodilatasi dan pada
pemaparan yang berulang, radiasi ini akan
menyebabkan pigmentasi (hipo / hiperpigmentasi) pada kulit. Luka bakar pada
kulit terjadi bila suhu kulit meningkat
sampai 45C.
246
Visible Light
Radiasi ini umumnya tidak berbahaya bagi
mata karena kita dapat mendeteksinya

sehingga bila mata terpajan cahaya yang
sangat kuat, secara gerak reflek pupil akan
menyempit dan kelopak mata akan
menutup sehingga pemajanan radiasi yang
berlebihan dapat dicegah.
Kebutaan dapat terjadi pada pemajanan
cahaya yang sangat terang, dan kebutaan
ini sifatnya adalah sementara.
247
Visible Light
Pemajanan terhadap cahaya yang luar
biasa terangnya misalnya seseorang yang

menatap matahari secara langsung tanpa
menggunakan alat pelindung mata, maka
hal ini dapat menyebabkan retina terbakar
sehingga orang yang bersangkutan
menjadi buta.
Intensitas pencahayaan yang tinggi atau
kesilauan dapat menyebabkan asthenopia
yang ditandai dengan kelelahan mata, sakit
kepala, rasa sakit pada mata dan iritasi
(keadaan ini sifatnya adalah reversible).
248
Visible Light
Visible light in the workplace can present problems
from both low and very high levels of illumination, as
well as poor contrast.
The eye responds to EMR in the region between 400
to 750 nanometres, and has a number of
adaptations (pupillary, lid closure, shading) to protect
the retina from over exposure.
249
Visible Light
The eye is most sensitive to light around
550 nanometres, but color vision requires
wide spectrum illumination (usually white
light) at an appropriate brightness level for
visual acuity. This helps differentiate
between very small and large objects.
250
Visible Light
The eye is also sensitive to glare or unwanted
light shining directly into the eye from the
direction in which it is trying to gather visual
information.
Both glare and shadows lead to visual fatigue
which, in turn, can lead to accidents. Moving
from bright light to areas of low illumination
can
be extremely hazardous, if there are moving
objects (e.g. forklifts, conveyors).
251
Visible Light
Good illumination for work conditions depends on
having the right quantity and the right quality.
Quantity refers to brightness, and quality refers to
distribution of illumination. The use of screen based
equipment in the office environment requires
attention to correct ambient levels of lighting,
absence of extraneous glare or reflections from the
screen.
252
Gelombang Mikro/Microwave
Microwave adalah suatu gelombang
elektromagnetik non ionisasi yang
mencakup suatu kisaran panjang
gelombang yang luas (1 mm sampai 1
m) dan frekuensi radiasi ini berkisar
antara 300 sampai 30.000 MHz (0,3
300 GHz).
253
Gelombang Mikro/Microwave
Sumber gelombang mikro antara lain
misalnya radar, televisi, berbagai peralatan
medis dan rumah tangga (microwave oven),
peralatan navigasi, telekomunikasi, dan lainlain.
Digunakan di industri untuk proses
pengeringan, curing plastic, proses
pengelasan (hardening) dan penyolderan
logam-logam dan lain sebagainya.
254
Efek Gelombang Mikro Pada Mata

Mata adalah sangat peka terhadap efek termis
radiasi elektromagnetik. Hal ini disebabkan

karena vaskularisasi pada jaringan tubuh ini
adalah kurang baik sehingga panas yang
diterima oleh lensa tidak dapat disalurkan ke
jaringan sekitarnya dengan akibat suhu lensa
akan meningkat.
Kenaikan suhu tersebut akan menyebabkan
denaturasi protein lensa dan akhirnya lensa
akan menjadi keruh dan berwarna putih.
255
Efek gelombang mikro pada sistem
reproduksi
Testis (buah pelir) adalah sangat rentan
terhadap efek termis radiasi gelombang
elektromagnetik. Pada intensitas pemajanan
yang tinggi, gelimbang mikro dapat
menyebabkan degenerasi sel-sel tubuli
seminiferous dan kemandulan yang sifatnya
tidak menetap. Kemandulan temporer ini lebih
banyak ditemukan pada mereka yang
mempunyai kebiasaan memakai celana dalam
yang ketat karena hal ini akan mengganggu
256
sirkulasi darah pada organ tersebut sehingga
Radiofrequency and Microwave
The possible effects of the interaction of

the
above mechanisms are as follows :
a. Radio-frequency (RF) burns
b. RF electric shock
c. Thermoregulatory responses
d. Cataract production
e. Pulsed radiation auditory effects
(RF hearing)
f. Cutaneous perception
257
Efek Biologis Gelombang

Mikro
Mata merupakan organ tubuh yang paling
peka terhadap radiasi elektromagnerik non

ionisasi.
Kerusakan mata terutama terjadi karena
pemajanan akut terhadap intensitas radiasi
UV yang tinggi misalnya pekerjaan
mengelas (las listrik).
Kerusakan mata dapat pula terjadi karena
pemajanan radiasi yang dipantulkan oleh
permukaan-permukaan yang mengkilap dan
atau berwarna cerah.
258
Efek Radiasi Ultraviolet

Pada mata, pemajanan radiasi UV
dapat menyebabkan peradangan pada
kornea (fotokeratitis) dan selaput mata
bagian luar (konjuktivitis).
Pada kulit, radiasi UV dapat

menyebabkan luka bakar, solar (actinic)
elastosis, solar keratosis, hipo atau hiper
pigmentasi dan kanker kulit.
259
Efek Radiasi Ultraviolet

Efek pada kulit terutama terjadi karena
pemajanan yang menahun pada dosis
radiasi yang rendah, dan terjadinya kelainan
kulit ini dipengaruhi oleh aklimatisasi
seseorang terhadap radiasi ini.
Pada pemajanan yang berulang dan
menahun, radiasi UV dapat menyebabkan
kulit menjadi kering, keriput dan berwarna
coklat, dan kelainan kulit ini semata-mata
terjadi pada individu-individu dimana kulit
mereka mengandung sedikit pigmen.
260
Exposure and Distribution of

ELF
The closer you live to HVTLs (High-Voltage

Transmission Lines), the more intense the
ELF field you receive from electric
transmission.
At the ground just beneath an HVTL, the
electric field strength is typically about 10
to 100 times as great as that found in the
immediate vicinity of common household
appliances.
261
Exposure and Distribution of

ELF
In contrast to electric fields, magnetic fields

produced a few inches away from household
electric currents are stronger than those
from HVTLs at the ground just below the
transmission lines.
262
Extremely Low Frequency

Radiation
Hazards : Extremely low frequency ( ELF) electric
fields act directly on the surface of a body as well
as inducing currents and fields inside the body.
At a cellular level this can cause direct stimulation
of excitable cells and accounts for person being able
to perceive an external field strength of 10 kV/m,
the induced current density is much smaller than 1
A/m2, which is the reported minimum level required
to stimulate excitable cells.
263
ELF RADIATION
Extremely low frequency magnetic fields induce
electric field in the body which result in current
flows through biological tissue. An external flux
density of 5 mT would result in current density of
1 A/m2.
Normal biological processes produce current
density in the body in the order of 1 mA/m 2. To
induce these levels, an external flux density of
65 uT would be required.
264
ELF Electromagnetic Fields
Hormonal secretion, calcium exchange, and

tissue growth could be affected by ELF fields
comparable in strength to those found in many
homes and workplaces.
It is the magnetic field, not the electric field,
within the ELF field that is particularly
hazardous.
265
ELF Electromagnetic Fields
People spending much of their workday in front

of computer terminal screens are likely to be
receiving more exposure to ELF fields from this
source than from all other sources combined.
Some studies indicate that the incidence of
birth defects and miscarriages afflicting
pregnant women who spend a considerable
part of the workday in front of a computer
screen is significantly greater than average.
266
Protection and Prevention

Do not buy a home located near an HVTL (High
Voltage Transmission Line) right-of-way.
Try to sit at least two feet away from a
computer screen.
Protective lap shields are available for pregnant
women who sit at computer terminals all day.
Avoid jogging or hiking trails that go directly
underneath HVTLs.
267
ELECTRIC FIELDS
Situation
Average Electric field

(v/m)
Average over typical

households
1 - 10
One foot from toasters, iron,

TVs, hair dryers
30-60
One foot from electric broilers
130
Covered by an electric blanket
Up to several thousand
but variable over body
Directly below an HVTL
10.000
268
MAGNETIC FIELDS
Situation
Average
magnetic field
(milliTeslas)
A few inches from soldering

guns and hair dryers
1-2
A few inches from other

appliances
0,1 - 1
On ground below an HVTL
0,035
269
Cold Stress
Pemaparan suhu udara rendah/sangat
rendah dapat menyebabkan :
1. Frosbite
2. Trench foot (immersion foot)
3. Hypothermia
270
Frosbite
Penyakit akibat suhu udara rendah ini terjadi bila
seseorang terpapar suhu udara yang sangat
rendah
atau kontak dengan benda yang sangat dingin
(exposed to extreme cold or contact with
extremely
cold objects).
Tanda dan gejala klinis frosbite :
Eritema (erythema)
Trombosis
Cyanosis (kulit berwarna kebiruan)
Gangrene
271
ERGONOMICS
Work
Demand
s
Safety
Wellness
Performance
Satisfaction
Comfort
Quality
Worker
Capabilities
The
Cockpit
Concept
274
275
276
What is Ergonomics ?
The science of
adapting the
workplace to
the worker.
277
Disiplin Ilmu
Ergonomi
Engineering
Fisiologi
Biomekanika
Antropologi
Psikologi
dan lain-lain.
278
Carpal Tunnel
Syndrome
The Carpal Ligament
The
Carpal
Tunnel
1
The Carpal Tunnel

You dont have to be handling heavy objects
to be
susceptible to CTDs.
Average keystroke requires 8 oz. of
pressure.
Assume: 6 keystrokes/word; 60
words/minute;
40 minutes/hour; 5 hours/day
Calculates out to 36,000 lbs./day (72,000
281
Pencegahan Kesilauan
Pencahayaan langsung
Posisi lampu pararel dengan to
users
line of sight
Appropriate window coverings
Matte work surface
Menaikan posisi monitor
Mengurangi perbedaan kontras
282
Workstation
Monitor : adjust for distance and height
(consider bifocals).
Glare : glare screens, adjust tilt, adjust
position and overhead lighting.
Document : alignment with monitor.
Should be at same height and distance
from worker as the monitor screen.
283
Work-related Disorders
Carpal Tunnel Syndrome

Tendonitis and Tenosynovitis
Low Back Disorders
Neck and Shoulder Pain
Eye Strain
284
Ergonomics Risk Factors
Posture & Position

Repetition / Frequency
Sustained Static Exertions
Forceful Exertions
Localized Contact Stresses
Individual Variability
285
Signs and Symptoms
Pain
Discomfort
Tingling
Numbness
Limited Movement
286
OFF-THE-JOB RISK FACTORS
Gardening
Sewing
Bowling
Biking
Carpenters
Musicians
Mechanics
Golfing
Hair Dressers
1
Adjust The
Tools, But Not Your Body
Chair
Keyboard
Monitor
Lighting
Mouse
Document stand
1
Adjusting Your Chair
Learn what your

chair can do
Adjust the height
Position your arms
Support your back
Rest your feet
1
Trench Foot (immersion Foot)
Trench foot terjadi bila seseorang terpapar

suhu rendah secara terus menerus dan
dalam waktu yang cukup lama serta yang
bersangkutan relatif dalam keadaan tidak
bergerak (relatively immobile).
Trench foot dapat disebabkan baik oleh
paparan suhu udara rendah atau tubuh
terendam dalam air yang dingin.
290
Trench Foot
Bagian tubuh yang terserang : kaki, ujung
telinga dan
hidung (the tips of nose and ears).
Tanda dan gejala klinis :
Penyempitan pembuluh darah (vasospasm),
Ischaemia, hyperaesthesia, pucat (pada
stadium dini), dan kemudin diikuti oleh
hyperaemia, paralisis vasomotor, vesiculasi
(vesiculation) dan pembengkakan kulit, serta
ganggrene (stadium akhir).
291
Hypothermia (general hypothermia)

biasanya terjadi bila seseorang terpapar
suhu udara rendah dan orang tersebut
melakukan latihan fisik.
292
Hypothermia terjadi pada saat orang
yang bersangkutan mengalami kepayahan

(exhaustion) sehingga mekanisme
perlindungan terhadap suhu udara rendah
yaitu penyempitan pembuluh darah
(vasoconstritive protective mechanism) akan
terganggu.
Sebagai akibat dari terganggunya mekanisme
perlindungan ini, maka secara tiba-tiba dapat
terjadi vasodilatasi sehingga tubuh akan
kehilangan panas (acute heat loss) dan
akhirnya penderita akan mengalami koma.
293
Lingkungan Hipobarik
Acute mountain sickness (AMS) adalah suatu
penyakit yang disebabkan oleh pemaparan
udara
atmosfir yang bertekanan rendah (hypobaric
exposure).
Penyakit ini ditandai dengan :
Sakit kepala
Mual
Muntah
Nafsu makan berkurang (anorexia)
Depresi (depression)
294
Acute Mountain Sickness jarang terjadi pada
ketinggian kurang dari 2000 meter. Penyakit ini
sering ditemukan pada mereka yang bekerja di
daerah penggunungan yang tinggi (diatas 3
Km) dan pekerja tersebut belum
beraklimatisasi terhdadap lingkungan
hipobarik.
295
Sembab paru (pulmonary edema) dapat
terjadi pada mereka yang mengalami
hipoksia yang berat (High-Altitude
Pulmonary Edema), dan sembab paru
biasanya terjadi setelah 24-60 jam
pemaparan.
296
Tanda dan gejala klinis High-Altitude Pulmonary
Edema (HAPE) adalah :
Sakit kepala
Sesak napas
Badan terasa lemah
Denyut nadi meningkat
Batuk (mula-mula nonproduktif dan kemudian
batuk darah)
297
Pembengkakan jaringan otak (cerebral

edema) biasanya jarang terjadi
Demam (fever)
Gejala neurologis yang dapat timbul
pada cerebral edema adalah sakit
kepala, gelisah, sempoyongan
(ataxia), dan halusinasi.
298
Lingkungan Hiperbarik
Pemaparan tekanan udara tinggi dapat

menyebabkan :
Penyakit dekompresi (decompression
sickness)
Narkosis akibat penghirupan gas nitrogen
bertekanan tinggi (nitrogen narcosis)
Keracunan oksigen (oxygen intoxication)
299
Penyakit Dekompresi
A. Tipe I (70-90% dari semua kasus DCS)
dengan tanda dan gejala klinis :
1. Ektremitas : rasa sakit pada sendi (the

bends),
rasa kaku, kesemutan, lemah dan bengkak.
2. Sistemik
: eritema, gatal, lelah, badan
panas, dan berkeringat. Penyakit DCS tipe I
ini bersifat akut.
300
Penyakit Dekompresi
B. Tipe II (10-25 % dari semua kasus yang
ditemukan)
1. Sistem kardiovaskuler dan pernapasan
- Nyeri dada
- Batuk
- Sesak napas (the chokes)
- Asfiksia
- Tachypnea
- Clotting time memendek
- Haemoconcentration
- Tamponade paru
301
Penyakit Dekompresi
C. Chronic Decomprssion Sickness
Nekrosis tulang (aseptic necrosis of
bone)
Paralisis (kelumpuhan) karena nekrosis
dan
degenerasi medula spinalis (spinal
cord).
302
Anthrax
Rare ---- due to Bacillus anthracis, sheep

and cattle pick up from infected pasture
(padand rumput) where it affects their blood
stream (septicaemia).
Workers at risk are wool sorters, farmers,
vets dokter hewan), stock handlers, and those
handling hides, hair etc., of diseased animals.
Spores may be inhaled or ingested by
humans giving rise to respiratory disease,
pustules. Animals must be totally destroyed.
Vaccines are available.
303
Leptospirosis
Caused by various Spirochaetes ---disease also known as Weils disease.

As a waterborne source of infection, may
affect river workers, sewer workers etc.
Causes fever, headache, pain and
nausea.
A related disease in dogs may affect dog
handlers or kennel (kandang anjing)
staff.
304
Hepatitis
Viruses of A, B, and C types.

Hepatitis B is most important in workplace.
Results from needle stick injuries in
workplace
or abraded skin contact with contaminated
blood.
Causes fever, headache, jaundice. May be
fatal.
Health care workers, ambulance, rescue
and
police are at risk.
Some people may be carriers without
showing
symptoms.
305
Psittacosis
Clamydia psittaci also known as Bird

fanciers
lung arises from many birds (parrots,
budgerigars
etc.)
Causes fever, headache and lung
pneumonitis.
Those keeping and handling birds are at risk.
Veterinary inspection is main control.
306
Destruction of
Microbiological Hazardous Materials
A.
B.
C.
Sterilization, usually by steam or by dry air

ovens.
Disinfection, using chemicals e.g. formaline
and formaldehyde gas, glutaraldehyde,
hypochlorite.
Incineration by complete burning in a high
temperature furnace.
307
Work Practices and

Employee Health Programs
Administrative controls including preemployment medical screening, regular
physical and medical checks, outplacement for
pregnant workers and maintenance of medial
records.
Restricting access to biohazard areas to
approved workers.
Standard work practice including restricting
eating and drinking in higher risk areas, proper
personal hygiene and disinfecting processes,
using special protective clothing which is not
worn outside the workplace.
308
Work Practices and

Employee Health Programs
D. Regular workplace disinfections or
decontamination procedures on programmed
basis of all floors, equipment, safety cabinets.
E. Vaccination programs when working with
certain infectious agents e.g. against hepatitis
B, small pox, tetanus, tuberculosis Q fever.
F. Proper identification and placarding with
approved biohazard warning signs.
G. Training of staff in a knowledge of hazards to
health, safe handling and disposal procedures.
309
Work-Related Musculoskeletal
Disorders
Work-related musculoskeletal disorders are

often
divided into three, though closely related,
classes of
problems :
Manual lifting and handling operations
Working postures
Cumulative trauma disorders ( CTS = Carpal
Tunnel Syndrome)
310
Components of The Stress Process
1. Stressors
Job structure --- overtime, shift work, machine
pacing, pace work.
Job content ---- Quantitative overload,
qualitative underload, lack of control.
Physical conditions --- unpleasant, threat of
physical or toxic hazard.
311
Components of The Stress Process

Stressors (continued)
Organization ---- role ambiguity, role conflict,

competition and rivalry.
Extra-organizational ---- Job insecurity, career
development, commuting.
Other sources ---- personal, family, community.
312
Outcomes
Physiologic :
Short-term ---- catecholamines, cortisol,
blood pressure increases.
Long-term ----- hypertension, heart
disease, ulcers, asthma.
Psychologic (cognitive and affective)
Short-term ---- anxiety, dissatisfaction, mass
psychogenic illness.
Long-term ---- depression, burnout, mental
disorders.
313
Outcomes
Behavioral :
Short-term --- job (absenteeism,
reduced productivity and participation),
community (decreased friendships and
participation), personal (excessive use of
alcohol and drugs, smoking)
Long-term --- learned helplessness.
314
Modifiers
Individual --- behavioral style
and personal resources.
Social support --- emotional,
value or self esteem, and
informational.
315
The following conditions may become

stressors
in work environments :
1. Job control, is the workers participation in
determining the job routine, including
control over temporal aspects and
supervising work processes.
2. Social support, means assistance through
supervisors and peers (teman sebaya). A
lack of social support increases the load of
stressors.
316
3. Job distress or dissatisfaction is mainly

related to job content and work load. It is the
perceived stress in job and career.
4. Task and performance demands are
characterized by the workload, including
demands upon attention. Deadlines may be a
major stressor, too.
5. Job security --- today refers mainly to the
threat of unemployment.
6. Responsibility for the lives and the well being
of other people may be a heavy mental burden.
317
7. Physical environmental problems include

noise, poor lighting, indoor climate or small,
enclosed offices.
8. Complexity is defined as the number of
different demands involved in a job. Repetitive
and monotonous work is often characterized
by a lack of complexity, which seems to be an
important predictor of job dissatisfaction. On
the hand, two high complexity can arouse
feelings of incompetence and lead to
emotional strain.
318
PHYSIOLOGICAL CONSEQUENCES
Studies have found that medical students

who are anxious (gelisah, cemas) about
their exams are more susceptible to colds
and other illnesses.
Many people experience tension
headaches due to stress. Others get
muscle pain and related back problems.
319
PHYSIOLOGICAL CONSEQUENCES
These physiological ailments are attributed

to muscle contractions that occur when
people are exposed to stressors.
Cardiovascular disease represents one of the
most disturbing effects of stress in modern
society.
Stroke and heart attacks were rare a century
ago but are now the leading causes of death
among American adults.
320
Stress also influences hypertension.
Hypertension has decreased in recent years

as a result of better lifestyles and medical
treatment. Still, nearly one-quarter of all
American adults are treated for this condition.
Medical researchers believe that the long-term
effects of stress on the heart goes something
like this : whenever people are stressed, their
blood pressure goes up and down. That
frequent pressure change causes injury to the
blood vessel walls, which eventually makes
them constrict and function abnormally.
321
Over time, this sequence leads to heart

disease. Unfortunately, we often can
not tell when we are physiologically
stressed. For example, researchers have
found that people think they are in a
low-stress state when, in fact, their
palms are sweating and their blood
pressure has risen.
322
Stress produces various psychological

consequences, including job
Dissatisfaction
and depression. Emotional fatigue is
another
psychological consequence of stress and is
related to job burnout.
323
In establishing a diagnosis of occupational

diseases, it is necessary for the physician to
encover several facts :
1. The place and the duration of employment
2. The details of the production process
3. The existence of confidential medical records
consisting of :
a. Pre employment medical condition
b. Periodic and annual examinations
c. Common illnesses encountered during
employment.
324
Diagnosis Penyakit Akibat kerja

Faktor-faktor yang mendukung diagnosis
penyakit
akibat kerja :
1. Anamnese (riwayat pekerjaan dan penyakit)
2. Pemeriksaan medik :
a. Fisik
b. Mental
c. Laboratorium
d. Pemantauan biologik (biological
monitoring)
e. Pemeriksaan radiologis
f. Patologi Anatomi (PA)
325
Diagnosis Penyakit Akibat Kerja

Lanjutan
3. Pemantauan lingkungan/cara kerja
4. Waktu paparan nyata
5. Hubungan antara bekerja/tidak bekerja
dengan gejala penyakit.
326
TERIMA KASIH
ATAS PERHATIANNYA
327

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1

WITH MONEY YOU

Tenaga kerja dalam melaksanakan

WHAT IS OCCUPATIONAL HEALTH ?

The discipline of occupational health

The main attributes and functions of a

The main attributes and functions of a

Teaching and research

k. Maintenance and review of clinical and

OCCUPATIONAL HEALTH NURSING

OCCUPATIONAL HEALTH NURSING

OCCUPATIONAL HEALTH NURSING

OCCUPATIONAL HEALTH NURSING

OCCUPATIONAL HEALTH NURSING

clinical intervention, including delivery

OCCUPATIONAL HEALTH NURSE

The role of the occupational health nurse has

OCCUPATIONAL HEALTH NURSING

It is important for everyone to understand

OCCUPATIONAL HEALTH NURSE

OCCUPATIONAL HEALTH NURSE

OCCUPATIONAL HEALTH NURSE

to both management and employees; therefore

OCCUPATIONAL HEALTH NURSING

No one can be expected to be

De Morbis Artificum Diatriba

TUJUAN KESEHATAN KERJA

PROGRAM KESEHATAN KERJA

PELAYANAN KESEHATAN KERJA

Permen Nakertrans No. 3 Tahun 1982

Permen Nakertrans No. 3 Tahun 1982

Tugas Pokok Pelayanan Kesehatan

Pemeriksaan kesehatan sebelum kerja,

Tugas Pokok Pelayanan Kesehatan

Tugas Pokok Pelayanan Kesehatan

Tugas Pokok Pelayanan Kesehatan

j. Membantu usaha rehabilitasi akibat

Dokter maupun tenaga kesehatan wajib

Masalah Kesehatan Kerja Di

Pengertian dan kesadaran pimpinan perusahaan

Masalah Kesehatan Kerja Di

beralasan bila perawat yang telah

Dokter perusahaan harus benar-benar

dapat bertindak sebagai occupational

PENYAKIT AKIBAT KERJA

Paracelsus sebagai seorang dokter di

Agricolas statement that in

The disease that prevailed in the mining

PENYAKIT AKIBAT KERJA

Permen Nakertrans No. 1 Tahun 1981

UU No. 3 tahun 1992 mengatur tentang

Kepres No. 22 Tahun 1993

Baik penyakit akibat kerja maupun penyakit

Menurut literatur dan bukan menurut

Work-related diseases may be partially

Outline of The Occupational

Descriptions of all jobs held

DESCRIPTIONS OF ALL JOBS HELD

questioned about working conditions

Work Exposure (Continued)

Further what the affected workers share in

Epidemiology of Symptoms or Illness

The patients knowledge of other workers

Non Work Exposure and Other